Soft skills in pPCI
Experience would tell us only about 70-80 % of STEMI are truly eligible for a good quality pPCI .(Multivessel CAD, Complex bifurcation lesion, difficulty in identifying IRA, No IRA-sapsms , complete spontaneous reperfusion ) The remaining 20-30 % should , logically be included in the failed pPCI category .This fact is largely concealed in the literature .
Beware of huge thrombus load in every patient with STEMI .The contribution of mechanical occlusion vs thrombus (in the total occlusion ) is the single most important factor in determining the intervention strategy.
Deploying a stent in a poorly prepared (debrided of thrombus ) lesion confers further continuous risk of a STEMI .Stents smartly jail even large thrombus against the coronary vessels and they release it into the lumen in a controlled fashion and prolong the acute coronary risk phases
If thrombus aspiration does a neat job and establishes a good flow , if the lumen appear good , think twice or even thrice before deploying a stent .It is akin to stent a zero % lesion and we know it is foolish to do that at any stretch of imagination .(Stenting has never been proven to convert a vulnerable ulcerated lesion into stable one )
IVUS, OCT are not the answer in the above situations as we are dealing with emergency coronary fire fighting !
Of course the intensive anti-platelet protocols , will take care of potential after effects of the intra coronary contact sport we play ! . But . . . there is a limit for every thing. So spend as little time as possible when attempting catheter based reperfusion during STEMI.
Dr.S.Venkatesan MD 